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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 4-8

Oral health status and its association with duration of dialysis among dialysis patients in Jodhpur city


1 Resident, Department of Public Health Dentistry, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India
2 Professor and Head, Department of Public Health Dentistry, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India
3 Associate Professor, Department of Public Health Dentistry, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India
4 Senior Lecturer, Department of Public Health Dentistry, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India

Date of Submission02-Jan-2021
Date of Acceptance03-Feb-2021
Date of Web Publication27-Mar-2021

Correspondence Address:
Dr. Supriya Sharma
Department of Public Health Dentistry, Vyas Dental College and Hospital, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpcdr.ijpcdr_1_21

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  Abstract 


Introduction: In the past three to four decades, improvements in dialysis and transplantation have reduced morbidity and mortality among patients with end-stage renal disease. The present study was conducted to establish the relationship of sociodemographic conditions, state of dental health, periodontal tissue, and soft tissue in patients with duration of hemodialysis.
Materials and Methods: A cross-sectional study using a self-administrated structured questionnaire was conducted among hemodialysis patients in Jodhpur city from March 2019 to June 2019. The final sample was 133 hemodialysis patients. The questionnaire was pretested on a group of ten patients to check the feasibility of the study and to ensure the face validity of the questionnaire.
Results: It was found that patients with more than 3 years on dialysis had a statistically significantly higher prevalence of decayed teeth. There was a strong correlation between length of time on Hemodialysis and decayed, probing pocket depth, clinical attachment level, periodontal indices, gingival index, bleeding on probing, and gingival recession.
Conclusion: Awareness must be raised among dialysis patients, nephrologists, and dentists about the need for primary dental prevention.

Keywords: Dentists, hemodialysis, kidney disease, oral health


How to cite this article:
Sharma S, Garla BK, Dagli RJ, Khan M, Das M, Dar A. Oral health status and its association with duration of dialysis among dialysis patients in Jodhpur city. Int J Prev Clin Dent Res 2021;8:4-8

How to cite this URL:
Sharma S, Garla BK, Dagli RJ, Khan M, Das M, Dar A. Oral health status and its association with duration of dialysis among dialysis patients in Jodhpur city. Int J Prev Clin Dent Res [serial online] 2021 [cited 2021 Apr 19];8:4-8. Available from: https://www.ijpcdr.org/text.asp?2021/8/1/4/312231




  Introduction Top


The diseases of the renal system pose a major cause of morbidity and mortality worldwide, among all the systemic disorders. Hemodialysis is an artificial means of removing nitrogenous and other toxic products of metabolisms from the blood. The number of patients with kidney failure, who require dialysis, is growing by 10%–1% annually.[1] In the past three to four decades, improvements in dialysis and transplantation have reduced morbidity and mortality among patients with end-stage renal disease. As survival has improved, it is necessary to focus on areas such as prevention in oral health of these patients to control risks of oral infections that could predispose to septicemia, endocarditis, and endarteritis possible vascular access.[2] It has been reported that periodontal disease/or poor oral hygiene increases the rate of bacteremia during dental procedures.[3],[4],[5],[6] Such bacteremia might present a potential risk for patients prone to infection, including dialysis patients. Dental health appears to be yet another area where attention has been lacking.

Chen et al.[7] speculated that early diagnosis and treatment of periodontal disease might reduce the high burden of cardiovascular disease in hemodialysis patients. Dental professionals must be aware of the most frequent oral manifestations of dialysis patients to ensure the correct management of such patients.[8],[9],[10],[11],[12] As there were scarce data regarding the dental status of the dialysis patients in Jodhpur city, the present study allowed us to establish the relationship of sociodemographic conditions, state of dental health, periodontal tissue, and soft tissue in patients with duration of hemodialysis.


  Materials and Methods Top


A cross-sectional study using a self-administrated structured questionnaire was conducted among hemodialysis patients in Jodhpur city from March 2019 to June 2019. The study was approved by the Ethical Committee of Vyas Dental College and Hospital, Jodhpur, and consent was obtained from the study object. The sampling frame comprised patients undergoing hemodialysis treatment in various dialysis centers of the Jodhpur city. Subjects included in the study were at least 16-year-old and were being treated with hemodialysis. Those patients refusing consent, patients under the age of 16 years, undergoing dialysis in satellite units and not attending the home clinic, and who underwent transplantation or died before the end of the study period were excluded from the study. The final sample was 133 with a response rate of 92.31%.

Questionnaire

A self-structured questionnaire in the English language was designed to record the patient's sociodemographic data, duration of dialysis, dialysis modality, smoking habit, and tooth cleaning habits, and medication history including the use of acetylsalicylic acid, nonsteroidal anti-inflammatory drugs, warfarin, antihypertensive, and immunosuppressive was recorded. History of diabetes, hypertension, anemia, heart disease, thyroid problem, and any other disorders was also recorded. The questionnaire was viewed by three dental public health as well as two urologists to ensure its suitability for the present study.

The questionnaire was pretested on a group of 10 patients to check the feasibility as well as face validity of the questionnaire and appropriate modifications were made. The reliability of the questionnaire was evaluated by (1) Cronbach's coefficient alpha to measure the internal consistency and (2) test–retest method to examine the stability of the questionnaire. The alpha coefficient of 0.79 was considered adequate. Test–retest reliability was measured by having the same set of respondents to complete a questionnaire at two different points of time within which there was no change of the constructs of interest. Intraclass correlation coefficient (ICC) with a 9% confidence interval was used for assessing this reliability. ICC measures the strength of agreement between repeated measurements. The value of the ICC was 0.72. An ICC 0.4–0.75 was an indication of fair to good reliability. The questionnaire was personally administered and the patients were explained regarding the motive of the study and how to complete the questionnaire. It was emphasized that the confidentiality of the responses made by them would be strictly maintained.

Each participant underwent an intraoral examination with the help of a mouth mirror, CPITN (clinical) probe, and light at the bedside while the patient attended the hemodialysis or home dialysis clinic. For assessing the thickness of plaque at the gingival area of the tooth, the plaque index (PI) of Silness and Loe was used.[8] The periodontal condition was examined using the probing pocket depth (PPD) to measure the distance between the bottom of the pocket and the margin of the gingiva from the six sites of each tooth (mesiovestibule, midvestibule, distovestibule, distolingual, midlingual, and mesiolingual). Evaluation of oral hygiene on the selected index teeth was performed according to the Oral Hygiene Index-Simplified.[9] The recording of decayed, missing, and filled (DMF) components was according to the rules of DMF teeth (DMFT) index (1997 modifications).[10] Evaluation of the gingival and periodontal status was done by using Community Periodontal Index.[11]

Statistical analysis

Data so collected were tabulated in an excel sheet, under the guidance of statistician. The means and standard deviations of the measurements per group were used for statistical analysis (SPSS 22.00 for windows; SPSS Inc, Chicago, USA). For each assessment point, data were statistically analyzed using factorial ANOVA. Difference between the two groups was determined using Chi-square test and the level of significance was set at P < 0.05.


  Results Top


[Table 1] shows that a total of 133 patients were registered for the study; of these patients, the ones undergoing hemodialysis for <1 years of HD were 53, whereas the ones undergoing HD for 1–3 years and for more than 3 years were 47 and 3,3 respectively. No statistically significant differences between the three groups were found with regard to age, gender, educational level, medical conditions (diabetes mellitus, hypertension, Ischemic Heart Disease (IHD), anemia, etc), tooth brushing frequency, use of dental floss, medications (corticosteroids, antihypertensive, anticoagulants, immunosuppressants), smoking habit, and the frequency of dental visits. [Table 2] shows that group with more than three years on dialysis had a statistically significantly higher prevalence of decayed teeth (P < 0.001) and larger DMFT index (P < 0.01). The mean values were statistically significant for all the Periodontal indices, except for bleeding on probing when compared among three groups. Poor periodontal health is associated with the duration of hemodialysis. [Table 3] shows that the length of time the subjects were on dialysis was statistically correlated to decayed, probing depth (PD), clinical attachment level (CAL), PII, gingival index (GI), and bleeding on probing (BOP) and there was a strong correlation between length of time on HD and decayed (r = 0.27, P < 0.05), PPD (r = 0.58, P < 0.01), CAL (r = 060, P < 0.01), PII (r = 0.47, P < 0.01), GI (r = 0.54, P < 0.01), BOP (r = 0.61, P < 0.01), and gingival recession (r = 0.58, P < 0.01).
Table 1: Demographical data of subjects on hemodialysis

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Table 2: Data regarding decayed, missing, or filled teeth, gingival index, probing pocket depth, gingival recession, clinical attachment level, bleeding on probing, and plaque index based on the duration of hemodialysis

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Table 3: The Pearson correlation coefficients between time on hemodialysis (months) and decayed, pocket depth, clinical attachment level, plaque index, gingival index, and bleeding on probing

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  Discussion Top


End-stage renal disease (ESRD) encompasses a wide range of metabolic disorders affecting every system of the body leading to a very immune-compromised situation. The incidence of ESRD continues to rise worldwide and in India, a conservative estimate of ESRD burden based on a population of 1.1 billion is that 1,650,000–2,200,000 people develop ESRD annually and as a consequence, an increasing number of individuals with such disease will probably continue to require oral health care. The present study compares the dental and periodontal status of 133 subjects with ESRD by the length of time they had been on HD.

Our results suggest a direct relationship of poor dental status with that of increase in the duration of HD. These results are in agreement with the findings of Sekiguchi et al.[13] in 2012 and Al-Wahadni and Al-Omari[6] in 2003 who suggested that it could be related to hyposalivation induced by the HD therapy. Saliva plays an important role in protecting the teeth from caries by removing microorganisms and cariogenic dietary components from the mouth. It has been suggested by Epstein et al.[14] in 1980 and Jaffe et al.[15] in 1986 that the caries activity in patients on dialysis is lower, as an increased urea concentration in saliva leads to higher pH levels.

According to Obry et al.[16] in 1987, higher salivary urea levels could potentially protect the teeth from demineralization but on the contrary, they enhance calculus formation in dialysis patients. Our results suggest a direct relationship of poor oral health with that of increase in the duration of HD that is subjects who have been undergoing HD for more than 3 years had deeper PDs, more attachment loss, more recession, more bleeding on probing, and more plaque deposits, which suggests that the longer a person was on HD, the more likely it could have a negative effect on oral health. The mean values for PD and CAL were statistically significantly higher in group with >3 years. These data were in agreement with the reports from Sekiguchi et.al.[13] in 2012, Duran and Erdemir[17] in 2004, and Cengiz et al.[18] in 2009 who found a positive correlation between length of time their subjects had been on HD and decrease in oral health status.

A strong correlation between the number of teeth with bleeding and the number of teeth covered with dental plaque and calculus was found. This is in agreement with previous studies by Bots et al.[19] in 2006 and Oshrain HI et al.[20] in 1979 on healthy individuals.

Limitations of the study

The limitation of the present study was its cross-sectional nature and that in spite of anonymous questionnaire, there are chances of hospital-based bias among the selected patients.


  Conclusion Top


It was concluded that subjects who were being treated with HD for more than 3 years had poorer periodontal health and a higher DMFT index score, suggesting that the length of time on HD could negatively affect the oral health status of these individuals. Thus, awareness must be raised among dialysis patients, nephrologists, and dentists about the need for primary dental prevention.

Public health significance

By consultation of the dentist during hemodialysis, an improvement in oral hygiene might reduce the amount of dental plaque and calculus, resulting in a reduction of the number of elements with bleeding. However, it should be taken into account that medication of HD patients, such as anticoagulant therapy, might mask the effect of an improvement of oral health measures.

Acknowledgments

We sincerely thank all the participants for their kind cooperation at different stages of this project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chamani G, Zarei MR, Radvar M, Rashidfarrokhi F, Razazpour F. Oral health status of dialysis patients based on their renal dialysis history in Kerman, Iran. Oral Health Prev Dent 2009;7:269-75.  Back to cited text no. 1
    
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Klassen JT, Krasko BM. The dental health status of dialysis patients. J Can Dent Assoc 2002;68:34-8.  Back to cited text no. 2
    
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Naugle K, Darby ML, Bauman DB, Lineberger LT, Powers R. The oral health status of individuals on renal dialysis. Ann Periodontol 1998;3:197-205.  Back to cited text no. 3
    
4.
Atassi F, Almas K. Oral hygiene profile of subjects on renal dialysis. Indian J Dent Res 2001;12:71-6.  Back to cited text no. 4
    
5.
Klassen JT, Krasko BM. The dental health status of dialysis patients. J Can Dent Assoc 2002;68:34-8.  Back to cited text no. 5
    
6.
Al-Wahadni A, Al-Omari MA. Dental diseases in a Jordanian population on renal dialysis. Quintessence Int 2003;34:343-7.  Back to cited text no. 6
    
7.
Chen LP, Chiang CK, Chan CP, Hung KY, Huang CS. Does periodontitis reflect inflammation and malnutrition status in hemodialysis patients? Am J Kidney Dis 2006;47:815-22.  Back to cited text no. 7
    
8.
Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontologica 1964;22:121-35.  Back to cited text no. 8
    
9.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.  Back to cited text no. 9
    
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World Health Organization. Oral Health Surveys Basic Methods. 4th ed. Geneva: World Health Organization; 1997.  Back to cited text no. 10
    
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Ainamo J. Epidemiology of periodontal disease. In: Lindhe J, editor. Clinical Periodontology. Buenos Aires: Editorial Médica Pan American; 1989.  Back to cited text no. 11
    
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Kher V. End-stage renal disease in developing countries. Kidney Int 2002;62:350-62.  Back to cited text no. 12
    
13.
Sekiguchi RT, Pannuti CM, Silva HT Jr., Medina-Pestana JO, Romito GA. Decrease in oral health may be associated with length of time since beginning dialysis. Spec Care Dentist 2012;32:6-10.  Back to cited text no. 13
    
14.
Epstein SR, Mandel I, Scopp IW. Salivary composition and calculus formation in patients undergoing hemodialysis. J Periodontol 1980;51:336-8.  Back to cited text no. 14
    
15.
Jaffe EC, Roberts GJ, Chantler C, Carter JE. Dental findings in chronic renal failure. Br Dent J 1986;160:18-20.  Back to cited text no. 15
    
16.
Obry F, Belcourt AB, Frank RM, Geisert J, Fischbach M. Biochemical study of whole saliva from children with chronic renal failure. ASDC J Dent Child 1987;54:429-32.  Back to cited text no. 16
    
17.
Duran I, Erdemir EO. Periodontal treatment needs of patients with renal disease receiving haemodialysis. Int Dent J 2004;54:274-8.  Back to cited text no. 17
    
18.
Cengiz MI, Sümer P, Cengiz S, Yavuz U. The effect of the duration of the dialysis in hemodialysis patients on dental and periodontal findings. Oral Dis 2009;15:336-41.  Back to cited text no. 18
    
19.
Bots CP, Poorterman JH, Brand HS, Kalsbeek H, van Amerongen BM, Veerman EC, et al. The oral health status of dentate patients with chronic renal failure undergoing dialysis therapy. Oral Dis 2006;12:176-80.  Back to cited text no. 19
    
20.
Oshrain HI, Mender S, Mandel ID. Periodontal status of patients with reduced immunocapacity. J Periodontol 1979;50:185-8.  Back to cited text no. 20
    



 
 
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